The proposed pilot project is a critical step towards the broader objective to improve functional outcomes of tendon transfer procedures in tetraplegia. Tendon transfers are surgical procedures in which the tendon of a muscle under voluntary control (donor muscle) is released from its insertion and is surgically attached to the tendon of a paralyzed muscle in order to restore function lost to paralysis. Individuals who undergo these procedures must learn to voluntarily activate the transferred muscle in its new anatomical location and more importantly to coordinate with new synergists during functional task performance. However, after surgery and conventional care, individuals do not fully activate the transferred muscle to perform its new function. Thus there is potential to advance rehabilitation programs that will improve surgical outcomes by improving postoperative performance with a muscle re-education and training program. Understanding how motor planning and control strategies determine postoperative upper limb function is essential for objective evaluation of current and prospective intervention protocols. The goal of this pilot project is to evaluate the effectiveness of a task-based home therapy program that follows tendon transfer to restore lateral pinch strength and conventional therapy. It is expected that a task-based program will address motor learning after transfer and result in improved voluntary activation of the transferred muscle as part of coordinated upper limb movements, important for producing pinch force in functional postures. Currently, patients must be discharged prior to receiving a focused re-training program. It is proposed that measurable increases in transferred muscle activation in functional postures will translate to improved upper limb performance. The specific objectives are to: 1. Evaluate the effectiveness of the proposed task-based home therapy program using clinical outcome measures to compare isometric pinch force magnitude, the ability to perform selected pinch tasks, and self- perceived performance before and after participation. 2. Assess training-related changes in the motor control of the transferred Br. Intramuscular EMG will be recorded to compare the activation of the transferred Br and the other elbow flexors during elbow flexion and pinch in various functional upper limb postures. The EMG will be quantified in terms of its magnitude and by using EMG decomposition to extract the recruitment and firing patterns of the active motor units. 3. Assess the effects of a task-based therapy for participants with different surgica outcomes to determine which individuals will benefit from task-based therapy and identify the mechanisms responsible for changes in motor performance. The ultimate goal of this work is to provide evidence that a task-based program should become part of the standard post-operative rehabilitation for individuals who receive tendon-transfer surgery. A more effective post-surgical rehabilitation program will lead to improved long-term functional outcomes following tendon- transfer and is intended to be effective in patients with both acute and chronic spinal cord injuries. These data will be used towards a broader study design for a prospective investigation of the effects of a focused rehabilitation intervention. The proposed time period for this pilot study is two years. Information gained from the proposed pilot study will be used to develop hypotheses and statistical power to guide a full-scale study to evaluate the capacity for improving tendon transfer surgical outcomes through task-based training. PUBLIC HEALTH RELEVANCE: The mission of the VA Palo Alto Health Care System, Spinal Cord Injury Service is to provide comprehensive treatment to maximize functional independence, enhance quality of life, and assist the individual regain and maintain his or her role in society. Of the over 100,000 individuals in the United States who have spinal cord injuries resulting in tetraplegia, 22% are veterans. Recovery of upper limb function has been ranked higher than bladder, bowel, and sexual function in this patient population and is an important goal in rehabilitation that will reslt in decreased medical costs and improved quality of life. The proposed pilot study addresses the need to examine traditional approaches to restoring upper limb function by evaluating the effectiveness of a novel task-based therapy program after tendon transfer and conventional therapy. This study will contribute to understanding the motor learning strategies that determine upper limb function and may lead to evidence- based rehabilitation protocols for improving upper limb performance in tetraplegia.